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The sharp end of medical care

“Where once a red cross would ensure protection, hospitals in Syria and Yemen are built underground and their GPS co-ordinates are kept secret.

“Clinical care is under fire. Our colleagues around the world are under fire. We are under fire.”

That was the stark warning from Australian doctor Dr Kathleen Thomas, who was working in a Médecins Sans Frontières (MSF) Trauma Centre in Kunduz in northern Afghanistan last October when it was bombed by the US military. 

Last month she spoke at a MSF Ireland event in Dublin and delivered a powerful and emotional recounting of her experience (see panel on p14). The Medical Independent (MI) was there to record Dr Thomas’s address, which received a standing ovation from the audience.

MSF has recently launched #NotATarget, which is a social media campaign against the targeted killing of civilians and humanitarians, to highlight the growing number of attacks on hospitals and medical staff in conflict zones.

With a number of high-profile bombings of hospitals in Syria, Yemen and Afghanistan, among other places, experts are suggesting that a worrying trend is emerging.

“There have been several important studies that have looked at the escalating attacks on healthcare workers and hospitals in Syria and in several other conflict areas,” Prof Michael VanRooyen, Professor in the Department of Global Health and Population at Harvard TH Chan School of Public Health, tells MI.

“From attacks on vaccinators in Pakistan and Nigeria, to bombing of hospitals in Syria and attacks on healthcare workers in Sudan, attacks against medical aid workers are increasing around the world.”

Prof VanRooyen is the author of the recently published book The World’s Emergency Room: The Growing Threat to Doctors, Nurses, and Humanitarian Workers (St Martin’s Press).

The trend has been chronicled by a number of medical organisations.

The International Committee of the Red Cross gathered data in 11 countries (including Afghanistan, Syria, South Sudan and Yemen), and between January 2012 and the end of 2014 it recorded 2,398 attacks against healthcare personnel, facilities and vehicles.

Syria, in the midst of a horrific five-year-long war, is one of the most dangerous locations for medical personnel. As of last month, Physicians for Human Rights (PHR) has documented 365 attacks on 259 medical facilities throughout the duration of the Syrian conflict and has recorded the deaths of 738 healthcare workers.

“PHR attributes more than 90 per cent of those attacks to the Syrian government and its Russian allies,” according to the PHR website.

So why is this trend happening now?

“Clearly, it is a growing problem,” Dr Thomas said during a questions and answers session following her Dublin address.

“I do wonder if [part of the reason is] the fact that the conflicts now are in non-traditional war zone settings, they are in cities where civilians are living,” she said.

Prof VanRooyen concurs, seeing the changing nature of conflicts as having a significant impact on medical safety.

“Over the past two decades, there has been a progressive erosion of humanitarian neutrality, leading to threats against all kinds of foreign aid workers and local staff working with international aid agencies,” he tells MI.

Prof VanRooyen says that this “erosion” of international humanitarian law standards has been made worse by the actions taken by combatants in many recent conflicts.

“The phenomenon has been exacerbated by combatants taking up residence in hospitals, and even by the CIA’s use of a medical worker posing as a vaccinator in Pakistan in an attempt to find Osama bin Laden,” he says. 

“These cases, however unusual, fuel the growing disregard for the neutrality of medical workers and hospitals.”

During Dr Thomas’s address in Dublin last month, she maintained that the international community must do more to combat these attacks.

“Despite calls from MSF and others, and a Security Council resolution, hospitals continue to be bombed.”

In May this year, the UN Security Council passed a resolution that was designed to stop future attacks against hospitals, patients and civilians in war zones.

So even if the experts are agreed that there are increasing safety challenges for medics in war zones, was there ever a ‘golden age’ for medical staff protection in a time of war?

Prof VanRooyen thinks the changes are complicated, but the nature of many of the current conflicts, such as civil wars often involving state actors and smaller non-state forces, may have increased the problems.

“In the 1980s and early 1990s, international aid organisations were allowed nearly unrestricted access to conflict areas,” he says. 

“As these civil conflicts, also referred to as ‘asymmetrical conflicts’, grew more complex, aid to civilians became increasingly politicised and exploited to control communities.

“I have seen the global aid community evolve significantly over the past 20 years, but we are not working in a completely different environment with new challenges.”

MSF Ireland Director Ms Jane-Ann McKenna also believes the international community has a significant role to play in calling for an end to these attacks. However, she added that each of these attacks takes place in a particular context.

“Every context and dynamic of a conflict is quite different,” she said during the questions and answers session at the MSF event last month.

“The perpetrators are quite different. You cannot say for certain in every context that it is a targeted attack.

“I think it’s very hard for us to say that there is a huge spike now in attacks on hospitals,” she said. “I don’t think there was any kind of golden era when everyone upheld international humanitarian law and hospitals were never attacked. 

“But we are seeing a pattern in the level of targeted attacks on a regular basis. It’s very hard to say for sure. But it is a worrying trend.”

In the Syrian civil war, attacks on hospitals have become more frequent. Most recently, The New York Times reported at the beginning of last month that “bombs from airstrikes hit three hospitals… in the rebel-held side of Aleppo, Syria, including a paediatrics centre supported by the United Nations.” The newspaper said that the Syrian government was the most likely culprit in this attack.

‘The most challenging week of my life’

Australian doctor Dr Kathleen Thomas was working in the Kunduz medical complex at the time of the US attack. Last month she was in Dublin at an MSF event and delivered a powerful and emotional retelling of her experience.  “This is obviously a very emotional journey for me to recount,” she said. “This is particularly difficult. This is the first time I have talked about it publicly but I know the audience is sympathetic.”

From 28 September 2015, major fighting broke out in Kunduz city. “So began the most personally and professionally challenging week of my life,” said Dr Thomas.

””

Dr Kathleen Thomas, an intensive care doctor from Australia

“For the whole week the emergency department and theatre were in overdrive, the wards were at 150 per cent capacity. The most pressing issue was how to staff the hospital, as the front line was rapidly changing.

“At times, we were smack-bang in the middle of the front line, stray bullets and shrapnel would often come over our walls into the compound. Moving in and out became dangerous. In the city, fighters filled the streets.  There were constant reminders that beyond our walls it was an unpredictable, dangerous city environment.

“We heard the fighter jets above us and the machine-gun fire was so close that we would instinctively lunge towards the ground.

“In the meeting [with staff] we relayed the message that we had been saying all week: ‘We believe the safest place to be right now is in the hospital. We cannot guarantee your safety outside the hospital, so therefore we advise that you stay with us in the hospital until things settle down.’ I truly believed those words; all of MSF truly believed them. Oh, how these words haunt me now.”

Dr Thomas had the highest praise for the local staff who worked in the hospital, some of whom were injured or killed.

 “The war took its toll on all of us. By the end of the week, we were physically exhausted and we were mentally and emotionally burnt out.”

She added that the Afghanis are a proud people “and they were very proud of this hospital”.

During a meeting with staff, they asked what people’s motivations were for coming into work, despite the huge dangers they faced when commuting to the facility from their homes.

“Most of them said ‘I want to make my family proud and my people proud and I am here to serve my community’. These are brave individuals who made a conscious choice,” she said.

Then on October 3, the hospital was bombed by the US military. According to MSF, when the aerial attack occurred, there were 105 patients in the hospital and 140 MSF international and national staff present, of whom 80 were on duty that night.

Dr Thomas, who was sleeping very near the hospital, explained that night she was “ripped awake from my sleep” by the noise. “I could feel the vibrations in my chest and covered my ears to protect my eardrums.  This was a totally different sound then anything we had heard that week. It was clearly very close. I felt adrenaline pumping through my body. My legs were shaking, my mouth was so dry and my hands were shaking.

“More explosions followed; they came in quick succession. We had no idea what was going on. It was dark in the room and we didn’t dare open the blinds.

“We scurried around the room, like rats in a cage, trying to find the safest place in case we took a direct hit. But we knew from the magnitude of that sound that in the case of a direct hit, there would be no safe place. We were overcome by gripping fear. The explosions continued one after another, separated by a short pause.”

She described a horrific scene in the hospital when she entered the main building, with staff and patients seriously injured.

“It’s hard to describe that feeling when you are surrounded by friends and colleagues, and they are begging for help and you have nothing to offer them,” she said.

“Forty-two patients were killed that night; 14 of them were our staff, countless others were injured, many of them suffering injuries that will make them unemployable in Afghanistan.

“The repercussions of this attack went far beyond the lives of those killed or injured. All of northern Afghanistan has been left without the Kunduz facility.”

Kunduz

Dr Thomas began working at the facility in Kunduz in Afghanistan four months before the attack in October 2015,

The MSF hospital was the only facility of its kind in north-eastern Afghanistan, providing free, high-level, life- and limb-saving trauma care. Since opening the hospital in 2011, more than 15,000 surgeries were conducted and more than 68,000 emergency patients were treated. It was a hugely important and successful facility staffed by local and international medical staff.

As in all its projects, MSF doctors treated people according to their medical needs and did not make distinctions based on a patient’s ethnicity, religious beliefs or political affiliation.

“Over four-and-a-half months, I had got used to the sounds of war in Afghanistan,“ said Dr Thomas.

But during a week of intense fighting at the end of September and beginning of October, “it was close, it was coming from all directions and it was constant”.

Her role was as supervisor of the ED and intensive care units. During the week of fighting where Taliban forces clashed with the Afghan army on the streets around the complex, there was a massive increase in workload for medics.

Then on Saturday, 3 October 2015, the MSF trauma centre in Kunduz was hit several times during sustained bombing by coalition forces. The facility was badly damaged and the total number of dead is known to be at least 42, including 24 patients, 14 staff and four caretakers.

The MSF hospital in Kunduz was substantially destroyed and is no longer operational. This leaves thousands of people without access to emergency medical care.

“The reality is the US dropped those bombs. The US hit a huge hospital full of wounded patients and MSF staff. The US military remains responsible for the targets it hits, even though it is part of a coalition,” Mr Christopher Stokes, General Director of MSF, said after the attack.

US President Barak Obama later apologised for the attack, and in April the US military released a heavily-redacted report of its own internal inquiry into the incident.

MSF has been critical of aspects of that report and is calling for activation of an international humanitarian fact-finding commission to investigate the bombing.

In Ireland, the Irish Nurses and Midwives Organisation (INMO) has already made representations to the Irish Government supporting an independent inquiry.

Separately, the IMO told MI last week that it has recently made a decision to write to the Irish Government to support a call for an independent inquiry into the bombing of the Kunduz facility.

“The IMO condemns all violence against healthcare workers and at the recent General Assembly of the World Medical Association (WMA) in Moscow in October 2015, the IMO voted to adopt the WMA Resolution about the bombing on the hospital of MSF in Kunduz,” an IMO spokesperson told MI.

“Following a recent council meeting, the IMO is writing to the Government to seek an independent inquiry into the bombing.”

MSF is calling for an independent investigation and MSF Ireland has had meetings with the Irish Department of Foreign Affairs about this issue.

A spokesperson for the Department of Foreign Affairs said:  “At the 32nd International Conference of the Red Cross and Red Crescent, which concluded in Geneva on 10 December 2015, Ireland was joined by all the Member States of the European Union in expressing alarm at the frequent lack of respect for medical missions in times of armed conflict and other emergencies. 

“We underlined the unacceptable character of attacks against medical personnel or patients, as well as any impediment to access to healthcare.”

The spokesperson added that the International Criminal Court (ICC) may be a possible route for an investigation.

“The Irish Government is a strong supporter of the International Criminal Court and consistently emphasises the independence of the Office of the Prosecutor in the performance of its investigatory and prosecutorial functions,” said the spokesperson.

“It is noted that in her Report on Preliminary Examination Activities of 12 November 2015, the Prosecutor includes mention of the attack on Kunduz Hospital in summarising her ongoing preliminary investigation of the situation in Afghanistan. The report indicates that ‘alleged crimes committed in Kunduz during the September-October 2015 events will be further examined’ by the Office of the Prosecutor”.

””

Future

So can anything be done about this worrying trend, not just in Afghanistan, but in Syria, Yemen, Ukraine and other locations? While many observers are sceptical that these problems can be managed during a period of large conflicts, others are attempting to begin initiatives to try and create safer environments for medical staff.

“This is a political and security issue, not a humanitarian issue,” says Prof VanRooyen.

“While many think that there is little chance of reversing this trend, there are efforts underway to educate combatants, influence policy-makers and hold those who commit crimes accountable. 

“That being said, military groups like ISIS and Al Shabaab have little respect for humanitarian norms. 

“It is unclear if this trend can ever improve, but our best bet is the unified advocacy work of ICRC, MSF and the UN to advance the cause of protection.”

*For more information about MSF’s campaign log on to www.msf.org/en/campaign/notatarget.

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